Radical excision and reconstruction of chronic tibial osteomyelitis with microvascular muscle flaps

We report a series of 21 patients with chronic osteomyelitis of the tibia treated with microvascular muscle flap reconstruction. All patients underwent a radical bone and soft-tissue excision until healthy, well-bleeding tissue was exposed. Six patients required cancellous bone grafting. Latissimus dorsi was used in 14 patients, gracilis in 4, and rectus abdominis in 4. One gracilis flap was lost due to vessel thrombosis and was replaced with a rectus abdominis free flap. Average follow-up was 2.5 years. There was no evidence of clinical infection in 20 patients at follow-up; the bone had healed, the soft-tissue cover was stable, and the laboratory parameters were normal. Bone infection recurred in 1 patient, resulting in a below-knee amputation. The radical excision of infected bone and affected soft tissue and reconstruction with a well-vascularized large free-muscle flap is an excellent solution in most difficult chronically infected cases.     

Brachytherapy tubes and free tissue transfer after soft tissue sarcoma resection

Irradiation commonly is used after resection of soft tissue sarcomas to decrease the local recurrence rate. Brachytherapy spares more normal tissue than external beam irradiation and permits irradiation to the tumor bed in the immediate postoperative period. After vascular anastomosis and irradiation, flap survival can be affected by vascular coagulation in the immediate postoperative period and later by vascular fibrosis secondary to irradiation effects. The purpose of the current retrospective study was to evaluate the survival of free tissue transfer when combined with brachytherapy after resection of soft tissue sarcomas. Thirty-six patients had wide resection of extremity tumors, free flap coverage, and brachytherapy 5 days after surgery. Followup averaged 54 months. There were three major and four minor complications. The major complications included two patients with free flaps who required revision of anastomosis before radiation therapy (they had brachytherapy 5 days after the second surgery without additional complications) and one patient who had a deep wound infection develop 2 months after the index procedure and required a second flap. Minor complications included one hematoma, one partial skin graft loss, and two superficial infections. Brachytherapy can be done safely at the site of microvascular anastomosis in the immediate postoperative period.     

Reconstruction of iatrogenic skin defects of the Achilles tendon region: an analysis of 25 consecutive patients

Achilles tendon surgery is quite common, typical indications being acute tendon rupture and chronic tendinitis. Post-operative wound infection or skin necrosis occurs in 2.4–5% of these operations. Soft tissue reconstruction of the Achilles tendon region presents a challenge due to the limited amount of local tissue available. We interviewed 25 consecutive patients with a post-operative skin defect, caused by infection or skin necrosis, after Achilles tendon surgery at mean 30 (range 6–56) months after reconstructive surgery. Of the patients 12 had acute tendon rupture and 13 had chronic tendinitis. The method of reconstruction after debridement was direct closure in one, total revision of the tendon and free skin graft in four, local flap in three, bipedicle skin flap in 10 and free microvascular flap in seven. All patients healed without event, however the patients whose reconstruction was done with a free flap had a somewhat slower return to work (mean 2.25 months vs 1.9 months) and had, after physical activity, pain in the operated area. We conclude that the type of soft tissue reconstruction in the Achilles area should depend on the size and shape of the defect as well as the general health of the patient.An invited commentary to this paper can be found at     

Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

OBJECT: Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage. METHODS: Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation. CONCLUSIONS: Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to "low-volume" defects.     

Postoperative infection after duraplasty with expanded polytetrafluoroethylene sheet

Dural reconstruction is a significant problem in many cases of decompressive craniotomy and dural defect. Expanded polytetrafluoroethylene (ePTFE) sheet have been used as a dura mater substitute for duraplasty. The outcomes of 83 consecutive patients at our institution were reviewed who underwent external decompression and closure with the ePTFE sheet between August 1995 and December 2000. Eight cases of infection occurred. Seven patients had infection with subdural empyema after cranioplasty with autologous bone. Three patients improved after removal of only the infected bone. One patient improved after removal of the infected bone and ePTFE sheet. One patient experienced wound infection after the original operation. Four patients subsequently developed local and severe inflammation with skin erythema until the ePTFE sheet was removed. Four patients had severe recurrent infections which required subsequent therapy such as vascularized free rectus abdominis muscle flap transfer. Duraplasty with ePTFE sheet might promote infection and poor circulation in the skin flap. The ePTFE sheet should be removed at an early stage in a patient with infection.     

Infections in neurosurgery: A retrospective study of 1143 patients and 1517 operations

Summary The files of 1143 neurosurgical patients, operated on between November 1, 1979 and June 4, 1981 were examined for records of post-operative infections. Eighty-three patients had developed infections (7%). In addition there were 33 instances of aseptic meningitis. Patients with a shunt were prone to infection (12%). Bone flap infections accounted for more than half of all infections after supratentorial craniotomy. Bacterial meningitis accounted for more than half of all infections after suboccipital craniotomy and translabyrinthine operations. In these patients bacterial meningitis was six times more common, and aseptic meningitis three times more common than in those who had had supratentorial operations. Shunt infection was more common after repeated shunt operations in quick succession. Craniotomy increased the risk of a shunt becoming infected.Antibiotic prophylaxis should be used not only in shunt operations but in all operations performed on patients with a shunt. If bacteria are recovered in a suspected shunt infection, immediate removal of the shunt is the best treatment. However, if the shunt's removal or replacement is exceptionally difficult intraventricular antibiotic treatment may be tried. The age of the patient, the duration of the operation, the individual surgeon and the number of operations did not affect the rate of infection. Clinical signs and conventional laboratory tests, apart from bacterial culture, cannot differentiate between bacterial and aseptic meningitis, but a drop in the level of consciousness suggests bacterial meningitis.     

Free Latissimus Dorsi Flap for Reconstruction of the Anterior Base of the Skull

Defects resulting after resection of malignant tumors of the paranasal sinuses involving the anterior base of the skull need an adequate closure. In addition to such avital tissue as fascia lata, fat, or ceramics, in recent years we used free muscle flaps from the latissimus dorsi for reconstruction. We performed this reconstructive method in seven patients after radical tumor ##. The operation was performed in cooperation with the neurosurgeon. In three cases a transfrontal in combination with a transfacial approach was used and in four cases only a transfacial approach was chosen. The flap was tailored as a pure muscle transplant if only the base of the skull had to be repaired and the surgical cavity had to be obhiterated. In three cases a skin paddle was left on the muscle to perform a closure of the orbit and the hard palate. In four patients we performed primary reconstruction, in three cases secondary reconstruction, which was necessary because cerebrospinal fluid (CSF) leakage occurred after primary reconstruction with avital tissue in addition to insufficient pericranial flap. None of the patients with primary reconstruction developed CSF leakage. There was no free flap failure. The aim of this reconstruction is a safe closure of skull base defects to prevent infection, meningitis, brain abscess, and brain herniation.     

Free latissimus dorsi flap for reconstruction of the anterior base of the skull

Defects resulting after resection of malignant tumors of the paranasal sinuses involving the anterior base of the skull need an adequate closure. In addition to such avital tissue as fascia lata, fat, or ceramics, in recent years we used free muscle flaps from the latissimus dorsi for reconstruction. We performed this reconstructive method in seven patients after radical tumor ##. The operation was performed in cooperation with the neurosurgeon. In three cases a transfrontal in combination with a transfacial approach was used and in four cases only a transfacial approach was chosen. The flap was tailored as a pure muscle transplant if only the base of the skull had to be repaired and the surgical cavity had to be obhiterated. In three cases a skin paddle was left on the muscle to perform a closure of the orbit and the hard palate. In four patients we performed primary reconstruction, in three cases secondary reconstruction, which was necessary because cerebrospinal fluid (CSF) leakage occurred after primary reconstruction with avital tissue in addition to insufficient pericranial flap. None of the patients with primary reconstruction developed CSF leakage. There was no free flap failure. The aim of this reconstruction is a safe closure of skull base defects to prevent infection, meningitis, brain abscess, and brain herniation.     

Die Deckung von Weichteildefekten und instabilen Narben über der Achillessehne durch freie mikrochirurgische Lappenplastiken

INTRODUCTION: Coverage of the exposed Achilles tendon requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result for the distal lower extremity. Various local flaps and free flaps have been described for reconstruction of small and large defects. Small defects can be closed with local tissue, whereas free flap coverage may be necessary for coverage of large defects. METHODS: From July 1993 to September 1998 14 patients between the age of 15 and 74 years (mean 47 years; 3 female, 11 male) underwent free flap coverage for the exposed Achilles tendon due to primary trauma, chronic wounds or tumors. The mean duration of follow-up was 33.3 months. The defect size ranged from 8 x 8 to 25 x 28 cm. RESULTS: Six parascapular flaps (three with a vascularized scapular fascial extension), four radial forearm flaps and four latissimus dorsi flaps (one combined with free serratus fascia) were used for soft tissue coverage over the Achilles tendon. Thirteen flaps survived. In one case a parascapular flap had to be removed due to venous thrombosis and a free latissimus dorsi flap was used as secondary salvage procedure. The donor site morbidity was acceptable for most patients after flap harvesting in the subscapular region and also satisfactory in the forearm region. Average active range of motion in the upper ankle joint was 15-0-40 degrees for extension/flexion. All patients were satisfied with the functional and aesthetic result. CONCLUSION: Soft tissue coverage over the exposed Achilles tendon requires an optimal solution for each patient to achieve an aesthetically pleasing result and acceptable function. Microvascular free flaps can be used to reconstruct medium and large defects and to provide gliding tissue for the Achilles tendon. The complication rate of microvascular flaps is comparable with that of local flaps.     

Microvascular reconstruction of complex craniofacial defects.

Many large vault or skull base tumours are best treated by wide surgical excision and primary reconstruction using a microvascular free tissue transfer (free flap). We report 23 patients who were reconstructed using free flaps, eight having been previously treated surgically elsewhere and seven of whom had recurrent disease after radiotherapy. There was one flap failure and a local recurrence rate of 16% (3/19). The outcome at a mean follow-up period of 29 months, was 19 patients alive and four deaths.     

吻合血管的游离肌肉瓣加网状皮片移植修复胫骨骨折合并骨外露及感染创面

目的介绍应用吻合血管的游离肌肉瓣加网状皮片移植修复胫骨骨折合并骨外露及感染创面的新方法。方法26例胫骨骨折合并骨外露及感染创面患者依伤情选择手术时机,5例采用一期吻合血管的游离肌肉瓣加网状皮片移植覆盖骨外露创面；6例急诊清创术后2周行二期修复；其余15例入院前胫骨远端感染严重,均采用二期肌肉瓣加网状皮片移植覆盖骨外露创面。结果26例中22例术后肌肉瓣及皮片全部成活；2例皮片部分坏死,2例创口延迟愈合,经换药均二期愈合。随访10～24个月(平均18个月),皮片色泽、质地、弹性均良好,无瘢痕挛缩。骨折均已愈合。结论肌肉瓣血运丰富,是修复胫骨远端感染及骨外露创面的理想方法,比较适合覆盖大面积软组织损伤合并骨外露创面和小腿远端慢性窦道及慢性骨髓炎骨外露创面。     

Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and without total knee arthroplasty

Nine patients with chronic extensor mechanism disruption were treated with an extended medial gastrocnemius rotational flap reconstruction of the extensor mechanism. Seven patients previously had total knee arthroplasty and two patients had chronic infection of nonreplaced, native knees. Four patients previously had failed Achilles' tendon allograft reconstruction after total knee arthroplasty and two were complicated by infection. Infected arthroplasty patients had a staged procedure with placement of an antibiotic spacer after debridement and extended medial gastrocnemius rotational flap, followed by total knee arthroplasty replant 8 weeks later. The four infected arthroplasty patients had medical comorbidities that included a patient with HIV and hemophilia, and two with diabetes mellitus. Another patient with rheumatoid arthritis was severely malnourished as a result of dumping syndrome. Of the four patients treated by this two-stage procedure, one died in the early postoperative period from chronic medical issues after the second stage and another patient elected to have above-knee amputation after the first stage because of severe reflex sympathetic dystrophy. The final group of seven patients was studied at a mean followup of 21 months (range, 7-31 months), the average extensor lag was 13.5 degrees (range, 0-50 degrees ), and the average range of motion was 2 degrees to 93 degrees . The two patients with nonreplaced, native knees had extensor lags of 30 degrees and 10 degrees . All patients were able to regain sufficient extensor mechanism strength to return to independent ambulation, and all infections resolved after treatment. Two patients were able to ascend stairs foot over foot without support. In addition to the patient who had amputation, the other complication involved a wound breakdown that required a free flap at 13 months in a patient who had a failed Achilles' tendon allograft reconstruction after takedown of a knee fusion. Medial gastrocnemius flap reconstruction can provide successful salvage of a failed extensor mechanism allograft or an alternative to allograft reconstruction in patients with poor soft tissue coverage, previous infection, or a compromised immune system.     

Radial forearm free tissue transfer reduces complications in salvage skull base surgery

OBJECTIVE: Patients who undergo skull base resection after prior surgery or radiation may be at high risk for complications when local flaps alone are used for reconstruction. To determine whether the complication rate could be reduced, fasciocutaneous free tissue transfer was used to reinforce the dural closure in patients who had prior skull base surgery or radiation. METHODS: This study is a case series of 20 patients (14 males, 6 females, aged 8-79 years of age with a mean of 47.7 years) from 1997 to 2001 who had prior skull base surgery or radiation, and underwent salvage skull base resection without large volume defects. All patients had a radial forearm free tissue transfer to reinforce the dural closure. Six patients had an osseous component to the forearm flap to provide vascularized bone to the orbital rim. RESULTS: The overall local complication rate was 35%. Three patients (15%) had major complications including 1 case of meningitis, 1 case of cerebrospinal fluid leak, and 1 case of a flap requiring venous salvage. There were no flap failures, 1 idiopathic median nerve palsy, and no pathologic radius bone fractures. CONCLUSION: Reconstruction with fasciocutaneous free tissue transfer for high-risk patients with low-volume dural defects following skull base resection can minimize the risk of major postoperative complications. EBM RATING: C.     

A comprehensive algorithm for anterior skull base reconstruction after oncological resections.

Objective: To present our method for anterior skull base reconstruction after oncological resections. Methods: One hundred nine patients who had undergone 120 anterior skull base resections of tumors (52 malignant [43%], 68 benign [57%]) via the subcranial approach were studied. Limited dural defects were closed primarily or reconstructed using a temporalis fascia. Large anterior skull base defects were reconstructed by a double-layer fascia lata graft. A split calvarial bone graft, posterior frontal sinus wall, or three-dimensional titanium mesh were used when the tumor involved the frontal, nasal, or orbital bones. A temporalis muscle flap was used to cover the orbital socket for cases of eye globe exenteration, and a rectus abdominis free flap was used for subcranial-orbitomaxillary resection. Pericranial flap wrapping of the frontonaso-orbital segment was performed to prevent osteoradionecrosis if perioperative radiotherapy was planned. Results: The incidence of cerebrospinal fluid (CSF) leak, intracranial infection, and tension pneumocephalus was 5%. Histopathological and immunohistochemical analysis of fascia lata grafts in reoperated patients (n = 7) revealed integration of vascularized fibrous tissue to the graft and local proliferation of a newly formed vascular layer embedding the fascial sheath. Conclusion: A double-layer fascial graft alone was adequate for preventing CSF leak, meningitis, tension pneumocephalus, and brain herniation. We describe a simple and effective method of anterior skull base reconstruction after resections of both malignant and benign tumors.     

Microvascular myocutaneous flaps in the lumbosacral area using the iliac artery and vein as recipient vessels.

Lumbosacral tissue defects are usually closed with local flaps. Sometimes in large high-situated defects free microvascular flaps are used. However, finding a suitable recipient vessel for microvascular anastomosis in this region is difficult. In large soft-tissue defects high in the lumbar area, closure with a free flap using the iliac artery and vein as recipient vessels channelled from the pelvic cavity to the back through a drill canal in a bone presents an alternative option where other vessels are damaged by radiotherapy or infection. This has been used successfully in two cases.     

Vastus lateralis muscle flap for infected hips after resection arthroplasty

We evaluated the potential of a vastus lateralis muscle flap in controlling infection after resection arthroplasty of the hip. We retrospectively reviewed 119 patients with 120 chronic infections after resection arthroplasty treated with this procedure. The flap was fixed with Mitek anchors in the acetabular cavity. The mean duration of infection after resection before the muscle flap procedure was 6.5 months (2 to 13). The patients had previously undergone a mean of 4.9 operations (2 to 25). In all patients the infected cavity was the origin of the persistent infection. The mean follow-up was for 2.6 years (1.0 to 4.7). No patient had recurrent infection post-operatively and all had an improvement in the pain and better quality of life.     

Late infection after cranioplasty--review of 14 cases

The incidence of late infection after cranioplasty was studied in 130 patients with 133 cranioplasties. The materials used were prefabricated resin in 62 cases, autogenic bone in 38, intraoperatively fashioned resin in 25, and vitallium in eight. Six infections were documented, for an infection rate of 4.5%. In addition to these six cases, we studied eight patients with infections who had undergone cranioplasty elsewhere but had the infected plates removed in our hospitals. Among the 14 cases of infection, the intervals between cranioplasty and plate removal were 3 to 43 months (average, 10.5 months). The eight patients referred from other hospitals had a significantly shorter average interval between external decompression and cranioplasty than did patients who did not develop infection (2.6 versus 6.7 months; p less than 0.005). Systemic signs were mild despite obvious local signs of infection. Of the 11 first infections, nine (82%) were associated with discharge of pus from a fistula; in these cases a galeal suture had become infected apparently through scratching by the patients. In contrast, in the three patients who had had a previous infection, the second infection manifested as subgaleal and epidural empyema or meningitis without a fistula or pus discharge. Nine infections (69%) were due to Staphylococcus. All but two patients required removal of the infected plates. One recovered with conservative therapy and one died of meningitis, giving a mortality rate of 0.8%. No matter how mild the systemic signs, late infection warrants surgical debridement and plate removal. The risk factors for late infection of cranioplasty are discussed.     

Vastus-lateralis-Lappen – Ein ideales Verfahren zur definitiven Sanierung von Infekthöhlen an der Hüfte

Between January 1994 and August 1998, 12 patients with 13 chronic infections after resection arthroplasty were treated successfully with vastus lateralis muscleflap. One patient was suffering from chronic infection on both sides. In all cases we found the infected cavity to be the origin of the persistent infection. The average duration of infection was 8.3 months. The patients had undergone an average of 3.8 operations. Up to now there was no recurrent infection, controlled by clinical investigation, ultrasound and laboratory findings in all 13 cases. Follow up investigation occurred 2.5 years (1.5-4.7) after flap transfer. The flap is easy to harvest. He has a very constant pattern of vascular pedicle and a wide arc of rotation. The functional deficits of donor side morbidity are minimal. That vastus lateralis flap seems to be an ideal procedure to stop draining infections due to infected cavities in the hip region.     

Trauma centre experience: flap reconstruction of traumatic lower limb injuries

BACKGROUND: Decision-making in the management of combined major skeletal and soft tissue trauma to the lower limb is a complex process made more difficult by the uncertainty surrounding outcomes. The aim of this study was to review and present our experience with flap reconstruction of traumatic lower limb defects, with particular reference to in-hospital complications and outcomes related to timing, choice of flap and pre-existing complications. METHODS: Retrospective review of all lower limb flap reconstructions carried out by the Plastic and Reconstructive Surgery Unit at the Alfred Hospital from 1 July 2001 to 20 October 2005 (51-month period) was carried out. RESULTS: Sixty-four patients had 83 flap reconstructions (35 free and 48 local) of 70 separate lower limb injuries. Internal skeletal fixation was followed by earlier soft tissue coverage and lower deep metal infection rates. Twenty-seven flaps (32.5%) developed soft tissue infections, and 16 fixation devices (25.8%) were complicated by deep metal infection. There were six (12.5%) local flap partial necrosis and four (11.4%) free flap failures. Limbs in which flaps were carried out after day 5 were more likely to develop deep metal infection (P = 0.04) and suffer free flap failure or local flap partial necrosis (P = 0.02). Three patients underwent secondary amputation during their initial admission. CONCLUSIONS: The current study presented our experience with flap reconstruction of complex lower limb injuries at a major trauma centre. Thorough wound debridement, internal fixation and early soft tissue coverage (within 5 days of injury) were associated with lower infection rates and optimal outcomes.     

Temporary arteriovenous shunt prior to free flap transfer

The establishment of a temporary arteriovenous shunt (TAVS) near a recipient site with inadequate local vessels may facilitate the subsequent re-vascularization of a free flap. In nine patients a TAVS was constructed prior to the transfer of free flaps. The indication was either the absence of vessels or inadequate recipient vessels. In eight of the nine patients the establishment of the shunt proved successful. In one patient a re-creation of the shunt was necessary owing to thrombosis caused by infection. In another patient the shunt thrombosed and no further microvascular surgery was possible. The construction of a TAVS increases the possibility of more extensive application of free flap transfer. Should the creation of the shunt prove futile, the donor flap may still be salvaged for further application. A staged transfer of a free flap after the primary establishment of a TAVS gives the best changes for adequate vascularization of the flap and reduces the risk of thrombosis.